20506 86TH PL W.PDF11111111111111
15433
20506 86TH PL W
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City of Edmonds
RIGHT-OF-WAY CONSTRUCTION
PERMIT
Number.
Lvsue Date:
A. Address or Vicinity of Construction: ;?e) 5,6
B. Type of Work (be specific):154� a P Ak,
/12 C.
C. Contractor: 441Z 4 4 Contact:
Mailing Address: 0 Phone:
State License #: Liability Insurance: Bond: $
D. Building Permit # (if applicable): Side Sewer Permit # (if applicable):
E. (:] Commercial E) Subdivision
E] Multi -Family E] Single Family
— I INSPECTOR:
El City Project V Tlfil�ty (PUD, GTE, WNG, CABLE, WATER)
E] Other
INSPECTOR:
F. Pavement or Concrete Cut: 0 Yes []No G. Size of Cut: x H. Chargq_$
APPLICANT TO READ AND SIGN
INDEMNITY: Applicant understands and by his signature to this application to hold the City of Edmonds harmlessfrom injuries, damages, or claims ofany
kind or description whatsoever, foreseen or unforeseen, that may be made against the City of Edmonds, or any of its departments or
employees, including or not limited to the defense of any legal proceedings including defense costs and attorneyfees by reason of granting this permit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MA TERIA LS FOR A PERIOD OF ONE YEAR FOLIO WING THE FINAL INSPEC-
TION AND ACCEPTANCE OF THE WORK. ESTIMATED RESTORATION FEES WILL BE HELD UNTIL THE FINAL STREETPATCHIS COMPLETED
BY CITY FORCES, AT WHICH TIME A DEBIT OR CREDIT WILL BE PROCESSED FOR ISSUANCE TO THE APPLICANT
Two sets of construction drawings of proposed work required with permit application.
A 24 hour notice is required for inspection. Please call the Engineering Division, 771-0220.
Work and material is to be inspected during progress and at completion.
Restoration is to be in accordance with City Codes.
Street shall be kept clean at all times.
Traffic Control and Public Safety shall be in accordance with City regulations as required by the City Engineer.
Al I street cut trench ' work shall be patched with asphalt or City approved material prior to the end of the working day;
NO EXCEPTIONS.'
I have read the above statements and understand the permit requirements and the pink copy of the permit will be
available on site at all times for inspection purposes.
Signature:
Date:
(Contractor or Agent)
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK
FOR CITY USE ONLY
APPROVED BY. 14 RIGHT OF WAY FEE: 00
TIME AUTHORIZED: VOID AFTJR 2-2- -4 -7 DAYS DISRUPTION FEE/FLYND I 11:
SPECIAL CONDITIONS: RESTORATION FEE:
T OTAL FEE: 30,00
RECEIPT NO.:
ISSUED BY:
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE Eng, Di� 1997
--707
FIELD INSPECTION NOTES (Fund 111 - Route copy to Street Dept.)
I Comments:
I Diagram.:
CONTRACTOR CALLED FOR INSPECTION YES NO
Partial Work Inspection by P.W.:
Work Disapproved By: Date:
FINAL APPROVAL BY: Date: